Top POEMs of 2012: Women's Health

BMD Screening Every 15 Years for Low-Risk Women

Clinical question: What is the best interval for repeat bone mineral density testing in older women?

Bottom line: The United States Preventive Services Task Force says that women should have an initial bone mineral density (BMD) test at age 65 years or at any age if their 10-year risk of fracture exceeds 10%. This study suggests that if the results of that initial screening test are normal or reveal only mild osteopenia in the femoral neck, the woman can wait 15 years before having a second examination. Those with moderate osteopenia should be retested at age 70 years, and those with severe osteopenia should consider annual testing until they are given a bisphosphonate. (LOE = 2b)

Reference: Gourlay ML, Fine JP, Preisser JS, et al, for the Study of Osteoporotic Fractures Research Group. Bone-density testing interval and transition to osteoporosis in older women. N Engl J Med 2012;366(3):225-233.

Study design: Cohort (prospective)

Funding source: Government

Setting: Population-based

Synopsis: The researchers used data from the Study of Osteoporotic Fractures, which recruited a cohort of 9704 women 65 years and older from Maryland, Minnesota, Pennsylvania, and Oregon (99% were white). Of this group, 4957 were 67 years or older, had either normal BMD or osteopenia, and had not experienced a hip or clinical vertebral fracture. Approximately 3 in 4 were between 67 and 74 years old, and 95% were nonsmokers. The goal of the research was to see how long it took before 10% of the women progressed from normal BMD or osteopenia in the femoral neck to osteoporosis (and therefore became candidates for bisphosphonate therapy), but before they experienced a fracture. They considered women with normal BMD, mild osteopenia (T score = -1.01 to -1.49), moderate osteopenia (-1.5 to -1.99), and advanced osteopenia (-2.0 to -2.49) separately. The results are surprising. For women with normal BMD or mild osteopenia -- essentially everyone with a T score greater than -1.5 -- it would take more than 15 years to progress to the point where they would be candidates for drug therapy. For women with moderate osteopenia it would take approximately 5 years, and for those with severe osteopenia only 1 year. A sensitivity analysis examining the effect of initial age, body mass index, and estrogen use did not significantly affect the findings.

Mark H. Ebell, MD, MS
Associate Professor
University of Georgia
Athens, GA

Only 800 IU Daily Dose of Vitamin D Is Effective at Reducing Fracture Risk

Clinical question: What is the optimal dose of vitamin D for fracture prevention?

Bottom line: A dose of 800 IU/day is associated with a lower risk of hip and vertebral fracture among persons over age 65 years. A higher baseline vitamin D level is also associated with lower risk of fracture, but this may be because higher levels are a marker of better health and good health habits (POEM 140305; Am J Clin Nutr 2011;94(6):1471-1478). (LOE = 1a)

Reference: Bischoff-Ferrari HA, Willett WC, Orav EJ, et al. A pooled analysis of vitamin D dose requirements for fracture prevention. N Engl J Med 2012; 367: 40-9.

Study design:  Meta-analysis (randomized controlled trials)

Funding source: Government

Setting: Population-based

Synopsis: The authors of this sytematic review pooled patient level data from 11 RCTs with over 30,000 participants. The mean age was 76 years, all participants were over 65 years of age, and about half were between 65 and 74 years. Also, 31% were living in institutions and 90% were women. In addition to looking at the patients by randomization to vitamin D or placebo (intention to treat analysis), they also looked at the actual vitamin D intake by participants, and how that was associated with fracture risk. They adjusted for age, residence, and sex in their analysis, and the primary outcome was hip and non-vertebral fracture risk. The mean daily intake of vitamin D was 100 IU in the control group, and 290 IU, 496 IU, 692 IU and 846 IU respectively in quartiles 1 through 4 of intake.The intention-to-treat analysis found a non-significant trend toward fewer hip fractures (RR 0.9, 95% CI 0.8 - 1.01) and a significant reduction in the risk of any non-vertebral fracture (RR 0.93, 95% CI 0.87 to 0.99, NNT = 120). The analysis by actual daily intake found no reduction in fracture risk for the three lower quartiles of dose, but did find a significant reduction in hip fracture risk (RR 0.71, 95% CI 0.58-0.87) and any non-vertebral fracture (RR 0.81, 95% CI 0.72-0.91) for those taking at least 792 IU per day. They also looked at the initial vitamin D level, and found decreased risk of fracture in those with levels above 30 nmol/L, with the lowest risk among those with levels greater than 60 nmol/L.

Mark H. Ebell, MD, MS
Associate Professor
University of Georgia
Athens, GA

 

Long-Acting Contraception Associated with Low Failure

Clinical question: How do the failure rates of long-acting reversible contraception methods compare with the pill, patch, and ring?

Bottom line: The contraceptive failure rate with intrauterine devices (IUDs) and implants is much lower than failure rates with contraceptive pills, patches, and rings. The IUD and implant failure rate was similar to that of depot medroxyprogesterone acetate (DMPA). The absolute difference in this study was approximately 4 pregnancies per 100 women-years of use. (LOE = 2b)

Reference: Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Eng J Med 2012;366(21):1998-2007.

Study design: Cohort (prospective)

Funding source: Foundation

Setting: Outpatient (primary care)

Synopsis: This was a prospective cohort study that enrolled 9256 women aged 14 to 45 years with a stated purpose of promotion of long-acting contraceptive methods (IUDs and implants). Eligible women were either not using a contraceptive method or were willing to change, did not want to become pregnant in the next year, were sexually active with a male partner or planning to become so within the next 6 months. Women were read a script that asserted that IUDs and implants were the most effective contraceptive method and they were counseled regarding the effectiveness, risks, and benefits of all reversible methods. Women then chose a method which was provided at no cost for 2 to 3 years, depending on the time of enrollment. Women could discontinue or switch methods as often as they wished. Women were interviewed at 3 months and 6 months, then every 6 months throughout the follow-up period. Periods of long-acting contraception were compared with use of pill, patch, ring, and DMPA. Periods of use of other methods, such as condoms or diaphragms, were excluded. Participants who thought they were pregnant were asked to come in for a urine pregnancy test. Contraceptive failure was defined as pregnancy occurring during use, but not if the participant stated that she had discontinued the method. If an IUD had been expulsed, pregnancy was considered to be a contraceptive failure if the woman was not aware of the expulsion. Use was measured in months and then expressed in woman-years. Overall failure rates with pill, patch, or ring were 4.8%, 7.8%, and 9.4% in years 1, 2, and 3, respectively. Failure rates with IUD or implant were 0.3%, 0.6%, and 0.9% in years 1, 2, and 3, respectively. Failure rates with DMPA were similarly low at 0.1%, 0.7%, and 0.7%. Overall failure rates per 100 woman-years were 4.6 with the pill, patch, or ring; 0.2 with DMPA; and 0.3 with an IUD or implant. The calculated hazard ratio for failure of long-acting methods compared with pill, patch, or ring after adjustment for age, education level, and number of previous unintended pregnancies was 22 (95% CI, 14-35). In subgroup analysis, women younger than 21 years using the pill, patch, or ring were twice as likely to have an unintended pregnancy as older women using those methods.

Linda French, MD
Professor and Chair, Department of Family Medicine
University of Toledo
Toledo, OH

POEMs are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com(www.essentialevidenceplus.com).

Advertisement